Br. J. clin. Pharmac. ( 1978), 5, 3-5
THE ROLE OF THE CLINICAL PHARMACOLOGIST IN DISTRICT GENERAL HOSPITALS Clinical Pharmacology Section British Pharmacological Society
Since its inception, the Clinical Pharmacology Section of the British Pharmacological Society has been discussing the wider role and responsibility of the clinical pharmacologist beyond the university department, in the district general hospital. The following policy statement is the product ofthese discussions, and is published in this international journal because, although the organization of the health service and its hospitals is peculiar to the United Kingdom, the concept of a clinical pharmacology service in general hospitals has far-reaching implications. The Editorial Board hopes that its publication will lead to recognition of the part that a general physician with a special interest in clinical pharmacology can play in patient care.
Clinical Pharmacology has emerged as a distinct academic discipline in Medical Schools and University Hospitals over the past fifteen years. Its development has been accelerated by the growth in knowledge of drug action, and by the increasing acceptance of the place of clinical pharmacological principles in the successful treatment of human disease. Clinical pharmacologists in university hospitals have been involved in teaching, research and direct patient care: their 'service' impact has been sufficiently striking for a number of individuals and groups to recommend their widespread deployment in the National Health Service (Clinical Pharmacology Section, BPS, 1977; Committee of Professors of Clinical Pharmacology and Therapeutics, 1977; Godber, 1974; MedicoPharmaceutical Forum, 1975; Royal College of Physicians, 1974). These recommendations have centred around the proposal that consultant clinical pharmacologists should be appointed to the staff of district general hospitals. Although the Department of Health and Social Security accepts the proposal, the contribution which clinical pharmacologists could make has been inadequately defined. It is the purpose of this document to draw attention to the expertise, skills and knowledge of trained clinical pharmacologists and to itemize the positive contributions that they can make to patient care.
Scope of training in clinicalpharmacology Clinical pharmacology can best be defined as the scientific study of drugs in man. Clinical pharmacologists in university hospitals inevitably have a strong commitment to research and teaching, but combine these activities with direct clinical responsibilities. There is a small number of general physicians with a special interest in clinical pharmacology in nonteaching centres (Davies, 1976) and we believe that it is individuals of this second category who are urgently needed.
Clinical pharmacology has its own Specialist Advisory Committee within the Joint Committee on Higher Medical Training, and training posts have been established and are being recognized in most university hospitals. Training in the discipline is similar to that of other specialties within internal medicine (Joint Committee on Higher Medical Training 1975): three years general professional training in general medicine is followed by four years higher specialist training divided equally between internal medicine and clinical pharmacology. Trainees may obtain accreditation in both internal medicine and clinical pharmacology and are therefore analogous to other general physicians with special interests (e.g. endocrinology, gastroenterology). In the course of their training, most clinical pharmacologists gain special expertise in the management of certain disorders (e.g. hypertension, epilepsy, obstructive airways disease), or in the use of particular classes of compound (e.g. anticoagulants, antiarrhythmic agents, analgesics, cytotoxic agents, antibiotics). They are thus able to offer expertise in general medicine, clinical pharmacology and a subspecialty.
Direct patient care Consultants appointed in clinical pharmacology to district general hospitals must combine general medicine with a special interest in their discipline. A major portion of the consultant's time will therefore be devoted to general medicine (including general medical outpatients and inpatients), participation in rotas, in emergency medical admissions and domiciliary visits. The consultant's special skills in clinical pharmacology would be deployed as follows: (a) The investigation and treatment of patients with drug-associated problems including 'failed' drug therapy and adverse drug reactions.
4
EDITORIAL
(b) The investigation and management of patients with poisoning from drugs and environmental, household or industrial chemicals. In some hospitals the investigation and management of poisoning with drugs might be seen as a primary responsibility of the clinical pharmacologist. (c) The provision of a clinical pharmacokinetic service in collaboration with the local chemical pathology service. The aim here is to provide advice on drug therapy based on kinetic considerations and the measurement of drug concentrations in body fluids. (d) The provision of advice to colleagues in other disciplines in the management of 'referred' patients. (e) The provision of a local drug information service, in collaboration with the hospital pharmacists, but including advice on therapeutics and clinical toxicology. (f) The investigation and management of patients with disorders appropriate to the individual's subspecialty (e.g. hypertension clinics, anticoagulant clinics, Parkinson's disease clinics). Teaching We place great emphasis on the educational potential of clinical pharmacologists at district general hospitals. The pace of drug development, the increasing knowledge of drug action and handling, and the marketing influences of the pharmaceutical industry mean that most doctors (and particularly those in general practice) find it difficult to cope with modern developments and need guidance. This teaching role would be directed particularly to:
(a) (b) (c) (d) (e)
pre-registration house-officers junior staff preparing for specialist diplomas general practitioners nurses
pharmacists
Experience with other specialties would suggest that the example set by a clinical pharmacologist in his clinical practice would have a substantial influence on prescribing in his hospital and in the community. Therapeutic ward-rounds, seminars and teach-ins for junior hospital staff and general practitioners would provide additional means for continuing education in drugs and drug therapy. The need for and benefits of improved prescribing are now increasingly recognized. It is highly probable that improvement in the quality of treatment and a substantial reduction in the drug bill could both be achieved.
Research We do not believe that sufficient time would be available for most individuals to undertake major research projects. However clinical pharmacologists at district hospitals should undertake or initiate clinical trials of new and established drugs as well as participate in multi-centre projects. They should encourage critical assessment of drug treatment not only among hospital staff but also among general practitioners. The Committee of Professors of Clinical Pharmacology and Therapeutics have indicated that some arrangement for formal or informal attachments of individuals to local academic units would be welcomed. Administration In addition to the administrative functions of any general physician, a specialist clinical pharmacologist could be expected to: (a) develop and monitor safe, efficient prescribing systems within his hospital (b) encourage sound prescribing policies in consultation with clinical and laboratory colleagues (c) advise his local District and Area Management Teams on drugs, and drug therapy (d) monitor drug costs in his District or Area in collaboration with hospital and retail pharmacists (e) maintain a good system of reporting adverse reactions of drugs.
Conclusion The members of the Clinical Pharmacology Section of the British Pharmacological Society believe that clinical pharmacologists can make major contributions to district general hospitals and the communities they serve by fulfilling the role outlined above. The appointment of such individuals could be accomplished in two ways. First, Areas and Districts might seek approval for the creation of new posts through the Regional Health Authority and the Department of Health & Social Security; the Department has indicated its willingness to consider such requests sympathetically. Second, Areas and Districts could consider replacing retiring general physicians with a physician offering clinical pharmacology as his special interest: such an approach would not require additional revenue but would obviously depend on the availability of vacancies, and local clinical needs.
EDITORIAL
5
References CLINICAL PHARMACOLOGY SECTION, BRITISH
PHARMACOLOGICAL SOCIETY (1977). Evidence to the Royal Commission on the National Health Service. COMMITTEE
OF
PROFESSORS
OF
CLINICAL
PHARMACOLOGY & THERAPEUTICS (1977). Evidence to the Royal Commission on the National Health Service. DAVIES, D.M. (1976). Clinical Pharmacology in a District General Hospital, Lancet, 1, 1063-1065. GODBER, G.E. (1974). In Anglo-American conference on
continuing medical education, p. 78. London: Royal Society of Medicine. JOINT COMMITTEE ON HIGHER MEDICAL TRAINING
(1975). Second Report. London: Royal College of Physicians. MEDICO-PHARMACEUTICAL FORUM (1975). Report of the Working Party on the continuing education of doctors in medicinal therapeutics. ROYAL COLLEGE OF PHYSICIANS (1974). Report of the Committee on Clinical Pharmacology.
THE ROLE OF THE CLINICAL PHARMACOLOGIST IN DISTRICT GENERAL HOSPITALS Clinical Pharmacology Section British Pharmacological Society
Since its inception, the Clinical Pharmacology Section of the British Pharmacological Society has been discussing the wider role and responsibility of the clinical pharmacologist beyond the university department, in the district general hospital. The following policy statement is the product ofthese discussions, and is published in this international journal because, although the organization of the health service and its hospitals is peculiar to the United Kingdom, the concept of a clinical pharmacology service in general hospitals has far-reaching implications. The Editorial Board hopes that its publication will lead to recognition of the part that a general physician with a special interest in clinical pharmacology can play in patient care.
Clinical Pharmacology has emerged as a distinct academic discipline in Medical Schools and University Hospitals over the past fifteen years. Its development has been accelerated by the growth in knowledge of drug action, and by the increasing acceptance of the place of clinical pharmacological principles in the successful treatment of human disease. Clinical pharmacologists in university hospitals have been involved in teaching, research and direct patient care: their 'service' impact has been sufficiently striking for a number of individuals and groups to recommend their widespread deployment in the National Health Service (Clinical Pharmacology Section, BPS, 1977; Committee of Professors of Clinical Pharmacology and Therapeutics, 1977; Godber, 1974; MedicoPharmaceutical Forum, 1975; Royal College of Physicians, 1974). These recommendations have centred around the proposal that consultant clinical pharmacologists should be appointed to the staff of district general hospitals. Although the Department of Health and Social Security accepts the proposal, the contribution which clinical pharmacologists could make has been inadequately defined. It is the purpose of this document to draw attention to the expertise, skills and knowledge of trained clinical pharmacologists and to itemize the positive contributions that they can make to patient care.
Scope of training in clinicalpharmacology Clinical pharmacology can best be defined as the scientific study of drugs in man. Clinical pharmacologists in university hospitals inevitably have a strong commitment to research and teaching, but combine these activities with direct clinical responsibilities. There is a small number of general physicians with a special interest in clinical pharmacology in nonteaching centres (Davies, 1976) and we believe that it is individuals of this second category who are urgently needed.
Clinical pharmacology has its own Specialist Advisory Committee within the Joint Committee on Higher Medical Training, and training posts have been established and are being recognized in most university hospitals. Training in the discipline is similar to that of other specialties within internal medicine (Joint Committee on Higher Medical Training 1975): three years general professional training in general medicine is followed by four years higher specialist training divided equally between internal medicine and clinical pharmacology. Trainees may obtain accreditation in both internal medicine and clinical pharmacology and are therefore analogous to other general physicians with special interests (e.g. endocrinology, gastroenterology). In the course of their training, most clinical pharmacologists gain special expertise in the management of certain disorders (e.g. hypertension, epilepsy, obstructive airways disease), or in the use of particular classes of compound (e.g. anticoagulants, antiarrhythmic agents, analgesics, cytotoxic agents, antibiotics). They are thus able to offer expertise in general medicine, clinical pharmacology and a subspecialty.
Direct patient care Consultants appointed in clinical pharmacology to district general hospitals must combine general medicine with a special interest in their discipline. A major portion of the consultant's time will therefore be devoted to general medicine (including general medical outpatients and inpatients), participation in rotas, in emergency medical admissions and domiciliary visits. The consultant's special skills in clinical pharmacology would be deployed as follows: (a) The investigation and treatment of patients with drug-associated problems including 'failed' drug therapy and adverse drug reactions.
4
EDITORIAL
(b) The investigation and management of patients with poisoning from drugs and environmental, household or industrial chemicals. In some hospitals the investigation and management of poisoning with drugs might be seen as a primary responsibility of the clinical pharmacologist. (c) The provision of a clinical pharmacokinetic service in collaboration with the local chemical pathology service. The aim here is to provide advice on drug therapy based on kinetic considerations and the measurement of drug concentrations in body fluids. (d) The provision of advice to colleagues in other disciplines in the management of 'referred' patients. (e) The provision of a local drug information service, in collaboration with the hospital pharmacists, but including advice on therapeutics and clinical toxicology. (f) The investigation and management of patients with disorders appropriate to the individual's subspecialty (e.g. hypertension clinics, anticoagulant clinics, Parkinson's disease clinics). Teaching We place great emphasis on the educational potential of clinical pharmacologists at district general hospitals. The pace of drug development, the increasing knowledge of drug action and handling, and the marketing influences of the pharmaceutical industry mean that most doctors (and particularly those in general practice) find it difficult to cope with modern developments and need guidance. This teaching role would be directed particularly to:
(a) (b) (c) (d) (e)
pre-registration house-officers junior staff preparing for specialist diplomas general practitioners nurses
pharmacists
Experience with other specialties would suggest that the example set by a clinical pharmacologist in his clinical practice would have a substantial influence on prescribing in his hospital and in the community. Therapeutic ward-rounds, seminars and teach-ins for junior hospital staff and general practitioners would provide additional means for continuing education in drugs and drug therapy. The need for and benefits of improved prescribing are now increasingly recognized. It is highly probable that improvement in the quality of treatment and a substantial reduction in the drug bill could both be achieved.
Research We do not believe that sufficient time would be available for most individuals to undertake major research projects. However clinical pharmacologists at district hospitals should undertake or initiate clinical trials of new and established drugs as well as participate in multi-centre projects. They should encourage critical assessment of drug treatment not only among hospital staff but also among general practitioners. The Committee of Professors of Clinical Pharmacology and Therapeutics have indicated that some arrangement for formal or informal attachments of individuals to local academic units would be welcomed. Administration In addition to the administrative functions of any general physician, a specialist clinical pharmacologist could be expected to: (a) develop and monitor safe, efficient prescribing systems within his hospital (b) encourage sound prescribing policies in consultation with clinical and laboratory colleagues (c) advise his local District and Area Management Teams on drugs, and drug therapy (d) monitor drug costs in his District or Area in collaboration with hospital and retail pharmacists (e) maintain a good system of reporting adverse reactions of drugs.
Conclusion The members of the Clinical Pharmacology Section of the British Pharmacological Society believe that clinical pharmacologists can make major contributions to district general hospitals and the communities they serve by fulfilling the role outlined above. The appointment of such individuals could be accomplished in two ways. First, Areas and Districts might seek approval for the creation of new posts through the Regional Health Authority and the Department of Health & Social Security; the Department has indicated its willingness to consider such requests sympathetically. Second, Areas and Districts could consider replacing retiring general physicians with a physician offering clinical pharmacology as his special interest: such an approach would not require additional revenue but would obviously depend on the availability of vacancies, and local clinical needs.
EDITORIAL
5
References CLINICAL PHARMACOLOGY SECTION, BRITISH
PHARMACOLOGICAL SOCIETY (1977). Evidence to the Royal Commission on the National Health Service. COMMITTEE
OF
PROFESSORS
OF
CLINICAL
PHARMACOLOGY & THERAPEUTICS (1977). Evidence to the Royal Commission on the National Health Service. DAVIES, D.M. (1976). Clinical Pharmacology in a District General Hospital, Lancet, 1, 1063-1065. GODBER, G.E. (1974). In Anglo-American conference on
continuing medical education, p. 78. London: Royal Society of Medicine. JOINT COMMITTEE ON HIGHER MEDICAL TRAINING
(1975). Second Report. London: Royal College of Physicians. MEDICO-PHARMACEUTICAL FORUM (1975). Report of the Working Party on the continuing education of doctors in medicinal therapeutics. ROYAL COLLEGE OF PHYSICIANS (1974). Report of the Committee on Clinical Pharmacology.
